O-1400, Youth Empowerment Services

Revision 14-4; Effective December 1, 2014

HHSC and the Texas Department of State Health Services (DSHS) received approval from the Centers for Medicare & Medicaid Services (CMS) to implement a Home and Community-Based Services Medicaid waiver, Youth Empowerment Services (YES). Section 1915(c) of the Social Security Act allows states to determine eligibility for certain persons seeking home or community-based medical assistance as if they were living in an institution. The YES waiver allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances and their families. The YES waiver began Sept. 1, 2009. To find out where YES is available for individuals, go to http://hhsc.texas.gov/doing-business-hhs/vendor-contractor-informati....

See Section O-1100, Application for Waiver Programs.

Waiver Eligibility Component

DSHS is responsible for determining if the person meets the criteria specific to YES for the waiver eligibility component and will communicate to HHSC that the person has:

  • an approved level of care (LOC)/medical necessity (MN) determination,
  • an approved individual plan of care (IPC), and
  • a service begin date no later than 30 days from certification.

HHSC will assume that DSHS has determined that the person:

  • is or will be residing in the community; and
  • is at least age 3, but under age 19.

If HHSC determines that the person is not residing in the community or does not meet the age requirement, communicate the discrepancy to DSHS. DSHS will take appropriate action and communicate back to HHSC.

Because Supplemental Security Income (SSI) parental deeming ends when a person reaches age 18, refer to the Social Security Administration (SSA) for an SSI determination. If certified for SSI, deny ME–Waivers. Notify the recipient of the change. Notify DSHS of the change. If the recipient never applies for SSI based on this referral, do not deny the Medicaid based on failure to apply for other benefits.

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to YES for the financial Medicaid eligibility component and will communicate to DSHS that the person has met all eligibility factors. If the person already is eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver already has been met. The Disabled Adult Child (DAC) program is an exception that requires a transfer to a Medicaid waiver.

Note: Even though the DAC program is in the Texas Medicaid State Plan, the YES waiver does not recognize this Medicaid program. If a recipient currently is certified for DAC and YES services have been requested, complete a program transfer and change the recipient from DAC to ME–Waivers in the Texas Integrated Eligibility Redesign System (TIERS). Reminder: A person must be age 18 to be eligible for DAC, and YES waiver eligibility ends at age 19. Flag the case to restore DAC benefits once the YES waiver ends, if the recipient continues to meet all other eligibility requirements.

When determining financial Medicaid eligibility for YES, give special consideration to the following:

  • Receipt of a signed and dated application. See Section O-1100, Application for Waiver Programs, and Section B-4000, Date of Application.
  • The child must be age 3 to 18. If the person is under age 65 and does not receive an SSA, SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required, even if the person has received an LOC determination under the DSHS waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of the penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's adult child with a disability, spouse or child is also living in the home.
  • Support, maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or a spouse, do not deem.
  • Income limit. Use the special income limit — 300 percent cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for YES at the initial application. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations made in TIERS.
  • Spousal impoverishment resources. If the person is married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

Multiple Program Processing

If there is a delay in certifying the waiver services because the person does not meet the DSHS waiver eligibility component criteria or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, use delay of certification procedures for the ME-Waiver eligibility determination group (EDG).

This allows the application to remain open for an additional 90 days.

DSHS notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the centralized mailbox (yeswaiver@dshs.state.tx.us). MEPD continues to notify DSHS of eligibility status using the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us).

When the person meets all pending DSHS waiver eligibility component criteria and there is an available slot, complete a disposition of the ME-Waiver EDG.

If the delay of certification period is expiring and the person still does not meet the DSHS waiver eligibility component criteria or there is still no available slot, proceed with denial of the ME-Waiver EDG. The MEPD specialist informs DSHS of the denial using the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us).

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME-Non-State Group Home, ME-State Hospital or ME-Nursing Facility) or CAS (ME-Community Attendant) and DAC MEPD Medicaid recipient, process a program transfer directly to ME-Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME-Waivers and waiver services have been authorized/received before the program transfer effective date, submit a help desk ticket to override existing coverage, such as DAC, to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if Form H1200, Application for Assistance — Your Texas Benefits, is needed. Verify resources and income, including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

Notices

When determining the financial Medicaid eligibility component, follow established notification procedures between the HHSC Office of Eligibility Services (OES) and DSHS.

If the applicant does not meet the financial Medicaid eligibility component criteria for YES Medicaid, send the appropriate denial notice to the person with a copy to the DSHS designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the DSHS designee.

Redeterminations of the financial Medicaid eligibility component follow an annual schedule. If a recipient fails to return the review form, HHSC will communicate to the DSHS designee that the recipient may be denied.

Co-Payment

To comply with the federally approved waiver, HHSC must calculate a co-payment for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which HHSC allows deductions. Allow deductions indicated on the appropriate co-payment worksheet. For YES, the co-payment usually will be $0 unless a QIT is involved. Notify the DSHS designee of the co-payment amount using the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us), even if the co-payment is $0 at the initial application. For redeterminations and reported changes, notify DSHS only if the co-payment amount changes.

Medical Effective Date (MED)

An MED can be established when the person meets all of the criteria for both the:

  • waiver eligibility component, and
  • financial eligibility component.

See Section R-1200, Medical Effective Date.

For waiver eligibility, the medical effective date is one of the following:

  • The first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, requested a program transfer before being certified, and met all eligibility criteria.
  • The first day of the month if the applicant met all waiver eligibility component criteria and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs.
  • The day after the effective date of SSI denial for people transferred from SSI assistance to an MEPD program (excluding any Medicare Savings Program).

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person also can be eligible under Category 2 for YES through Texas Works Medicaid. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21. Refer the person to SSI at age 18. If the recipient becomes SSI-eligible, HHSC notifies DSHS YES staff via the Medicaid Eligibility to DSHS centralized mailbox (yeswaiver@dshs.state.tx.us) that the recipient's coverage is being transferred to SSI. HHSC must then terminate ME-Waivers coverage to allow SSI eligibility to process.
  • Restitution and reconciliation policy does not apply.